Healthcare Provider Details

I. General information

NPI: 1366622672
Provider Name (Legal Business Name): ANDREW DONALD DYBALA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MILL AVE
TEMPE AZ
85281-6699
US

IV. Provider business mailing address

1500 S MILL AVE
TEMPE AZ
85281-6699
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-5533
  • Fax:
Mailing address:
  • Phone: 480-784-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3727
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: